Pioneers in 5 Star Service • Ronstadt Insurance • Tucson, AZ • 520-721-4848

Out-of-Pocket Costs: 4 Things to Know

  1. A deductible works like your car insurance. It’s the amount you pay before your insurance benefits kick in. Let’s say you have a plan with a $1,000 deductible. You would pay the first $1,000 for the services you use. After that, your plan would pay its share. You still pay any copays or coinsurance. 
  2. A copay is the fixed or set dollar amount ($25, for example) you pay for certain covered healthcare. Prescriptions and visits to a doctor in your network are examples of covered services that often have copays.
  3. Coinsurance is the percentage of costs of covered healthcare service you pay after you’ve paid your deductible. Let’s say the allowed amount to see a specialist visit is $100 and your coinsurance is 20 percent. Your cost is $20 if you’ve already paid your annual deductible. Your plan would pay the remaining 80 percent, or $80.
  4. The out-of-pocket maximum is the most you pay in a year before your health insurance pays 100 percent of the cost of covered, in-network services. The out-of-pocket maximum puts a cap on healthcare costs if you ever have a major illness or injury. 

Tip! This maximum does not include your monthly premium or services that your plan doesn’t cover. Costs for services from providers outside your network do not apply to this limit.

So how do out-of-pocket costs translate to real life? Let’s look at a real-life example.

Alan has to have his gallbladder taken out, which will cost $55,000. What will he have to pay?

The deductible: Alan has a $4,000 deductible for the year. He hasn’t yet paid any of it yet, so he’ll pay $4,000.

The coinsurance: Alan has a 20% coinsurance for the surgery. However, that’s 20% of the allowed amount. His health plan’s allowed amount is $35,000. Alan is using an in-network provider, so his coinsurance is 20% of $31,000 (that’s the $35,000 allowed amount minus the $4,000 deductible) instead of $55,000.

The out-of-pocket maximum: Alan’s plan has a $6,650 out-of-pocket maximum. 

Alans’s cost summary:
Allowed amount:  $35,000
Deductible: $4,000
Difference:  $31,000

Coinsurance: $6,200 (20% x 31,000)
Total: $10,200

What Alan pays:  $6,650

Alan is protected by his out-of-pocket maximum, so he pays $6,650 instead of $10,200. That’s how health coverage helps protect both your health and your wallet!

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